When asked to define a health system, most people immediately point to the tangible, visible elements: the local general hospital, the neighborhood health center, the clinician they visit when illness strikes. This common framing is understandable—these are the touchpoints that patients interact with directly, the parts of care that we experience firsthand. But according to Grenadian health expert Dr. Ishma Harford, a functional health system runs far deeper than the surface-level components the public sees, much like an anthill where only a fraction of the colony’s complex infrastructure is visible above ground.
To illustrate this dynamic, Harford draws an analogy between health systems and anthills. From the outside, any casual observer can see worker ants moving back and forth, foraging for food and tending to the colony’s daily needs. What remains hidden from view is the extensive network of underground tunnels, storage chambers, and coordinated organizational structures that make all that above-ground activity possible. The ant carrying a leaf across the anthill’s surface is just the final, visible outcome of a massive, unseen infrastructure—just as a nurse attending to a patient at a health center is the endpoint of a sprawling, underrecognized system that shapes every interaction.
Many of the most frustrating problems patients face do not originate at the point of care, Harford argues. When a patient waits multiple hours to be seen by a provider, the issue is not simply a slow reception desk. When a needed medication goes out of stock, the breakdown does not start at the hospital pharmacy. These negative patient experiences are just surface-level symptoms of deeper failures rooted in the hidden layers of the system: inadequate public funding for healthcare, underinvestment in ongoing workforce training, and unaccountable governance structures that lack mechanisms for course correction when problems arise.
Worse still, Harford notes that some systemic failures do not stay hidden. Many gaps in care are identified, documented, and debated by stakeholders, yet no action is ever taken to address them. This inaction, he emphasizes, is also a systemic failure—and it is perhaps the most inexcusable one of all.
This is why adopting a whole-system perspective that examines both visible service delivery and hidden underlying structures matters so much. Taking this view is not about excusing poor quality care; it is about identifying the true root causes of negative patient experiences. The care a patient receives on the surface is shaped long before they walk into a health facility, shaped by decisions made behind closed doors and debates about resource allocation that patients are never invited to join. Understanding this is not an abstract academic exercise: it equips patients and advocates to direct their questions to the right actors and hold decision-makers accountable for failures.
Back in 2007, the World Health Organization (WHO) outlined six core building blocks that form the foundation of every functional health system, covering everything from the healthcare workforce to medication access, health technology, leadership, and governance. In the WHO framework, patients were positioned as the end goal of the entire system—the final outcome that all six building blocks exist to serve. But in recent years, public health researchers have pushed back against this framing, arguing that treating patients only as the final destination of care allows system designers, funders, and governing bodies to ignore patient voices, needs, and lived experiences throughout the process of building and running the system.
Harford goes even further in his argument: patients are not just the end goal of a health system—they are its core premise. The most critical component of any health system is you: every current or future patient who relies on care. Without patients, a health system has no function, no mandate, no reason to exist. Every budget line, every policy, every structural building block exists for one single purpose: to protect and improve your health. Harford argues that systems must be built around this central fact, not treat it as an afterthought added once the structure is already in place.
In closing, Harford poses a central question for Grenada’s healthcare system: Are the core building blocks of Grenadian healthcare actually structured around the needs of patients? And if they are not, what steps must stakeholders take to steer the system back on course?
Dr. Harford is a medical clinician with five years of hands-on experience working within Grenada’s health system, and currently a Master’s candidate in Health Analysis, Policy and Management. His column *The Health Imperative* is an educational, politically neutral platform exploring the meaning of health, the systems that deliver care, and the broader implications of health policy for communities. NOW Grenada notes that it is not responsible for the opinions and statements shared by contributing writers, and provides a channel for readers to report abusive content.